Abstract
Objective:
To evaluate the association of sex and pregnancy status with rates of naloxone administration during opioid overdose-related emergency department (ED) visits using the Nationwide Emergency Department Sample (NEDS).
Methods:
A retrospective cohort study was conducted using NEDS 2016 and 2017 datasets. Eligible records included men and women, 15–49 years of age, with an opioid overdose-related ED visit; records for women were stratified by pregnancy status (ICD-10 O codes). A multivariable logistic regression model was used to assess the primary outcome of naloxone administration (CPT code: J2310). Secondary outcomes included subsequent admission and mortality. A subgroup analysis compared pregnant women who did versus did not receive naloxone.
Results:
Records from 443,714 men, 304,364 non-pregnant women, and 25,056 pregnant women were included. Non-pregnant women had lower odds for naloxone administration (1.70% vs 2.10%; aOR: 0.86(0.83–0.89)) and mortality (2.21% vs 2.99%; aOR: 0.71(0.69–0.73)) but higher odds of subsequent admission (30.22% vs 27.18%; aOR: 1.04(1.03–1.06)) compared with men. Pregnant women had lower odds for naloxone administration (0..27% vs 1.70%; aOR: 0.16(0.13–0.21)) and mortality (0.41% vs 2.21%; aOR: 0.28(0.23–0.35)) but higher odds of subsequent admission (40.50% vs 30.22%; aOR: 2.04(2.00–2.10)) compared with non-pregnant women. Pregnant women who received naloxone had higher odds of mortality (14% vs 0.39%; aOR: 6.30(2.11–18.78)) compared with pregnant women who did not receive naloxone. Pregnant women who did not receive naloxone were more likely to have Medicaid as their expected insurance payer, be in the lowest quartile of median household income for residence ZIP code, and have a concurrent mental health diagnosis compared with pregnant women who did receive naloxone.
Conclusion:
Reproductive-aged non-pregnant and pregnant women were less likely to receive naloxone during opioid overdose-related ED visits compared to reproductive-aged men. Naloxone administration for reproductive-aged women should be prioritized in the efforts to reduce opioid- and pregnancy-related morbidity and mortality in the United States.
Introduction:
Opioid-related deaths increased annually for two decades prior to 2018.1–6 The rate of increase in opioid-related deaths in females—particularly women of reproductive age (15–49 years of age)7—was greater than the rate of increase for males. Concurrently, reproductive-aged women have the highest rates of drug misuse- or abuse-related emergency department (ED) visits among women.1 The United States’ (US) maternal mortality ratio has also increased, particularly following the implementation of the Pregnancy Mortality Surveillance System.3,8–12 Maternal mortality review committees have identified drug overdose as a leading cause of pregnancy-related mortality in the US13, necessitating novel ways to identify risk factors and conduct surveillance to mitigate this significant public health problem.
Guidelines and recommendations from medical societies and public health agencies support administration of naloxone to pregnant women in the setting of suspected opioid overdose.14–15 However, limited studies have evaluated the effectiveness of emergency departments in administering naloxone specifically to pregnant women; further, few studies have evaluated the effectiveness of naloxone administration based on sex or gender.16–17
The Nationwide Emergency Department Sample (NEDS), developed for the Healthcare Cost and Utilization Project (HCUP) with the Agency for Healthcare Research and Quality (AHRQ), is the largest all-payer ED database in the US and estimates about 145 million ED visits each year.20–21 NEDS—along with other HCUP databases—has been studied to report on opioid-related hospitalizations and ED visits.22–23 The aim of this study was to compare rates of naloxone administration for reproductive-aged men, non-pregnant women, and pregnant women with opioid overdose-related ED visits using the NEDS. Our null hypothesis is that the rates of naloxone administration will not differ among reproductive-aged men, non-pregnant women, and pregnant women.
Methods:
A retrospective cohort study was conducted using NEDS, a sample from the State Inpatient Databases and State Emergency Department Databases to create national and regional estimates of ED care for patients initially seen in the ED and then admitted to the same hospital, as well as patients with ED visits that do not result in admission.20 This research was qualified as exempt research under the Department of Health and Human Services regulations by the Johns Hopkins Medicine Institutional Review Board. No identifiable data were available to the researchers.. Eligible records of contemporaneous data from the 2016 and 2017 datasets included men and women with an opioid overdose-related ED visit defined using the following 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes: T40.0–40.4, T40.6, F11, F19, O99.32, R41.82, or I46.9 (Appendix 1, available online at http://links.lww.com/xxx). These codes were selected based on previous research1,22–24, guidance for researchers from public health agencies25, and the recognition that ED coding for opioid overdose-related exposures and symptoms is not uniform26. The exposure variable was defined as being female. The unexposed comparison cohort was age-matched men. Men and women not of reproductive age as defined by the World Health Organization (15–49 years of age)7 or records where age was missing were excluded. Women of reproductive age with opioid overdose-related ED visits were stratified by pregnancy status (ICD-10 O codes including those associated with the postpartum period). In our cohort, less than 2% of records with ICD-O codes had codes associated with the postpartum period and a subgroup analysis was not performed. Women who did not have a diagnosis of pregnancy are further referred to as non-pregnant women. The recommendations of the Strengthening the Reporting on Observational Studies in Epidemiology (STROBE) and REporting of studies Conducted using Observational Routinely-collected Data (RECORD) statements for undertaking observational research were used to perform this research.
Demographic details were described at the patient and ED facility level. Patient level characteristics included age, expected insurance payer, median household income for residence ZIP code, urban-rural designation of residence27, and concurrent diagnosis of depression, anxiety or other mental health disorder (ICD-10 F codes) (Appendix 1 [http://links.lww.com/xxx]). ED facility level characteristics included geographical region in the US, trauma center level, urban-rural designation27, and teaching status. The primary outcome was administration of naloxone (Current Procedural Terminology (CPT) code: J2310). Secondary outcomes included subsequent admission from ED to ED facility (further referred to as subsequent admission), and mortality in ED or after admission to ED facility (further referred to as mortality).
Comparisons were made between all reproductive-aged non-pregnant women and similarly aged men, and between reproductive-aged pregnant women and all reproductive-aged non-pregnant women. A subgroup analysis was also performed comparing pregnant women who received naloxone versus pregnant women who did not receive naloxone.
Stata 14.2 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP.) was used for statistical analyses. Descriptive statistics (analysis of variance) were used to compare the demographics of the groups. Two-tailed P-values were reported and a P-value of 0.05 was used to define statistical significance. Univariate logistic regression was used to determine the probability of occurrence of the primary and secondary outcomes within the groups, and to calculate crude odds ratios (ORs). Potential confounding factors were adjusted for in a multivariable logistic regression model. The factors included age, expected insurance payer, quartile of median household income for residence ZIP code, rural designation of residence, concurrent diagnosis of depression or anxiety, any concurrent mental health diagnosis, ED facility region, ED facility trauma center level, ED facility urban-rural designation, and ED facility teaching status. As we had a small number of outcome events and the adjusted model included many covariates, a propensity score matching analysis was performed for the primary outcome. The results were consistent with those from our multivariable logistic regression model (Appendix 2 [http://links.lww.com/xxx]). Records with missing data (other than age) were not excluded from the analysis. Both unadjusted and adjusted odds ratios (aORs) were calculated along with 95% confidence intervals.
Results:
Overall, there were 659,330 records of women and 794,923 records of men with opioid overdose-related ED visits. After application of exclusion criteria, 329,420 records of reproductive-aged women and 443,714 records of similarly aged men with opioid-overdose related visits were included (Figure 1). Among reproductive-aged women, 304,364 were non-pregnant and 25,056 were pregnant.
Figure 1.
CONSORT (Consolidated Standards of Reporting Trials) flow diagram for inclusion and exclusion of records in Nationwide Emergency Department Sample database. Opioid overdose-related International Classification of Diseases, Tenth Revision (ICD-10) codes: T40.0–40.4, T40.6 F11, F19, O99.32 R41.82, I46.9. Centers for Disease Control and Prevention ICD-10 codes for pregnancy: O00–9A. CPT code for naloxone administration: J2310. World Health Organization defined women of reproductive age: 15–49 years. ED, emergency department.
Pregnant women were younger than non-pregnant women and men (Table 1). The majority of each group was insured by Medicaid, with the highest frequency among pregnant women. More pregnant women were in the first quartile of median household income for residence ZIP code, whereas more men had a metropolitan residence. The majority of each group had a concurrent mental health diagnosis, but the frequency was highest for pregnant women and the diagnosis was less likely to be depression or anxiety. Non-trauma centers, metropolitan teaching hospitals, and ED facilities in the South (Appendix 3, available online at http://links.lww.com/xxx) had the largest percentage of opioid overdose-related ED visits based on ED facility characteristic.
Table 1.
Baseline characteristics of study population
| Men | Non-pregnant women | Pregnant women | P | |
|---|---|---|---|---|
| Patient Characteristic | (n=443,714 unless specified) | (n=304,364 unless specified) | (n=25,056 unless specified) | |
| Age in years, mean (SD) | 32.96 (8.72) | 33.28 (8.90) | 27.38 (5.49) | <0.01 |
| Expected insurance, n (%) | (n=442,767) | (n=25,010) | <0.01 | |
| Medicaid | 184,172 (41.6)* | 144,312 (47.5) | 18,071 (72.3) | |
| Private | 86,717 (19.6) | 60,738 (20.0) | 3,262 (13.0) | |
| Self-pay | 118,383 (26.7) | 56,765 (18.7) | 2,270 (9.1) | |
| Other | 53,495 (12.1) | 41,833 (13.8) | 1,407 (5.6) | |
| Quartile of median household income for ZIP code, n (%) | (n=425,677) | (n=295,634) | (n=24,528) | <0.01 |
| Q1 | 146,872 (34.5) | 104,502 (35.4) | 10,987 (44.8) | |
| Q2 | 106,600 (25.0) | 78,864 (26.7) | 6,548 (26.7) | |
| Q3 | 91,710 (21.5) | 63,185 (21.4) | 4,409 (18.0) | |
| Q4 | 80,495 (18.9) | 49,083 (16.6) | 2,584 (10.5) | |
| Urban-rural designation of residence, n (%) | (n=432,439) | (n=299,656) | (n=24,789) | <0.01 |
| Metropolitan | 380,769 (88.1) | 256,399 (85.6) | 21,678 (87.5) | |
| Non-metropolitan | 51,670 (12.0) | 43,257 (14.4) | 3,111 (12.6) | |
| Concurrent diagnosis, n (%) | ||||
| Depression or anxiety | 65,968 (14.9) | 68,948 (22.7) | 2,987 (11.9) | <0.01 |
| Any mental health | 348,996 (78.7) | 236,125 (77.6) | 20,319 (81.1) | <0.01 |
| ED Facility Characteristic | ||||
| Region, n (%) | <0.01 | |||
| Northeast | 108,967 (24.6) | 63,600 (20.9) | 3,794 (15.1) | |
| Midwest | 83,786 (18.9) | 62,193 (20.4) | 4,992 (19.9) | |
| South | 166,300 (37.5) | 122,136 (40.1) | 11,479 (45.8) | |
| West | 84,661 (19.1) | 56,435 (18.5) | 4,791 (19.1) | |
| Trauma center level, n (%) | (n=436,311) | (n=299,234) | (n=24,692) | <0.01 |
| Not a trauma center | 205,987 (47.2) | 150,540 (50.3) | 10,556 (42.8) | |
| Level I | 103,747 (23.8) | 60,189 (20.1) | 7,133 (28.9) | |
| Level II | 72,505 (16.6) | 48,801 (16.3) | 3,896 (15.8) | |
| Level III | 54,072 (12.4) | 39,704 (13.3) | 3,107 (12.6) | |
| Urban-rural designation, n (%) | <0.01 | |||
| Metropolitan | 401,380 (90.5) | 268,542 (88.2) | 22,670 (90.5) | |
| Non-metropolitan | 42,334 (9.5) | 35,822 (11.8) | 2,386 (9.5) | |
| Teaching status, n (%) | <0.01 | |||
| Metropolitan non-teaching | 115,692 (26.1) | 84,366 (27.7) | 5,999 (23.9) | |
| Metropolitan teaching | 285,688 (64.4) | 184,176 (60.5) | 16,671 (66.5) | |
| Non-metropolitan | 42,334 (9.5) | 35,822 (11.8) | 2,386 (9.5) | |
Percentages may not compute to 100% due to rounding.
Primary and secondary outcome results are summarized in Table 2. Non-pregnant women had lower odds for ED naloxone administration (1.70% vs 2.10%; aOR: 0.86 (0.83–0.89)) and mortality (2.21% vs 2.99%; aOR: 0.71 (0.69–0.73);) but higher odds of subsequent facility admission (30.22% vs 27.18%; aOR: 1.04 (1.03–1.06)) compared with men. Pregnant women had lower odds for ED naloxone administration (0.27% vs 1.70%); aOR: 0.16 (0.13–0.21)) and mortality (0.41% vs 2.21%; aOR: 0.28 (0.23–0.35);) but higher odds of subsequent facility admission (40.50% vs 30.22%; aOR: 2.04 (2.00–2.10)) compared with non-pregnant women.
Table 2.
Primary and secondary outcomes for reproductive-aged non-pregnant women versus men, and pregnant women versus non-pregnant women with opioid overdose-related emergency department visit
| Men |
Non-pregnant women | Pregnant women | Non-pregnant women versus men |
Pregnant women versus non-pregnant women |
|||
|---|---|---|---|---|---|---|---|
| (n=443,714) | (n=304,364) | (n=25,056) | Un-adjusted OR (95% CI) |
Adjusted OR (95% CI)† |
Un-adjusted OR (95% CI) |
Adjusted OR (95% CI)† |
|
| Naloxone Administration, n (%) |
9,303 (2.10) | 5,186 (1.70) | 69 (0.27) | 0.81 (0.78–0.84) | 0.86 (0.83–0.89) | 0.16 (0.13–0.20) | 0.16 (0.13–0.21) |
| Subsequent facility admission, n (%) |
120,611 (27.18) | 91,972 (30.22) | 10,136 (40.5) | 1.16 (1.15–1.17) | 1.04 (1.03–1.06) | 1.57 (1.53–1.61) | 2.04 (2.00–2.10) |
| Mortality, n (%) |
13,289 (2.99) | 6,734 (2.21) | 102 (0.41) | 0.73 (0.71–0.75) | 0.71 (0.69–0.73) | 0.18 (0.15–0.22) | 0.28 (0.23–0.35) |
Adjusted for age, expected insurance payer, national quartile of median household income for residence ZIP code, rural designation of residence, concurrent diagnosis of depression or anxiety, any concurrent mental health diagnosis, ED facility region, ED facility trauma center level, ED facility urban-rural designation, and ED facility teaching status.
Comparisons between pregnant women who received naloxone and pregnant women who did not receive naloxone are summarized in Tables 3 and 4. Pregnant women who did not receive naloxone were statistically more likely to have Medicaid as their expected insurance payer, be in the lowest quartile of median household income for residence ZIP code, and have a concurrent mental health diagnosis compared to pregnant women who did receive naloxone. The distribution of records differed based on region of the US. There were no other differences in ED facility characteristics (Table 3).
Table 3.
Baseline characteristics for pregnant women who received versus did not receive naloxone
| Pregnant women who did not receive naloxone | Pregnant women who received naloxone | P | |
|---|---|---|---|
| Patient Characteristic | (n=24,987 unless specified) | (n=69) | |
| Age in years, mean (SD) | 27.38 (5.49) | 28.67 (5.84) | 0.053 |
| Expected insurance payer, n (%) | (n=24,941) | <0.01 | |
| Medicaid | 18,036 (72.3)* | 35 (50) | |
| Private | 3,250 (13.0) | 12 (17) | |
| Self-pay or no charge | 2,252 (9.03) | 18 (26) | |
| Other | 1,403 (5.63) | 4 (6) | |
| Quartile of median household income for residence ZIP code, n (%) | (n=24,459) | <0.01 | |
| Q1 | 10,967 (44.8) | 20 (29) | |
| Q2 | 6,527 (26.7) | 21 (30) | |
| Q3 | 4,396 (18.0) | 13 (19) | |
| Q4 | 2,569 (10.5) | 15 (22) | |
| Urban-rural designation of residence, n (%) | 0.159 | ||
| Metropolitan | 22,611 (90.5) | 59 (86) | |
| Non-metropolitan | 2,376 (9.5) | 10 (15) | |
| Concurrent diagnosis, n (%) | |||
| Depression or anxiety | 2,984 (11.9) | 3 (4) | 0.052 |
| Any mental health | 20,288 (81.2) | 31 (45) | <0.01 |
| ED Facility Characteristic | |||
| Region (%) | <0.01 | ||
| Northeast | 3,781 (15.1) | 13 (19) | |
| Midwest | 4,968 (19.9) | 24 (35) | |
| South | 11,451 (45.8) | 28 (41) | |
| West | 4,787 (19.2) | 4 (6) | |
| Trauma center level (%) | (n=24,623) | 0.311 | |
| Not a trauma center | 10,525 (42.7) | 31 (45) | |
| Level I | 7,125 (28.9) | 8 (12) | |
| Level II | 3,881 (15.8) | 15 (22) | |
| Level III | 3,092 (12.6) | 15 (22) | |
| Urban-rural designation (%) | 0.159 | ||
| Metropolitan | 22,611 (90.5) | 59 (86) | |
| Non-metropolitan | 2,376 (9.5) | 10 (15) | |
| Teaching status (%) | 0.193 | ||
| Metropolitan non-teaching | 5,973 (23.9) | 26 (38) | |
| Metropolitan teaching | 16,638 (66.6) | 33 (48) | |
| Non-metropolitan | 2,376 (9.51) | 10 (15) | |
Percentages may not compute to 100% due to rounding.
Table 4.
Secondary outcomes for pregnant women who received versus did not receive naloxone with an opioid overdose-related ED visit
| Pregnant women who did not receive naloxone | Pregnant women who received naloxone |
Pregnant women who received naloxone vs pregnant women who did not receive naloxone | ||
|---|---|---|---|---|
| (n=24,987) | (n=69) | Un-adjusted OR (95% CI) | Adjusted OR (95% CI)† |
|
| Subsequent facility admission, n (%) |
10,137 (40.6) | 0 (0) | -- | -- |
| Mortality, n (%) |
98 (0.39) | 4 (14) | 15.53 (5.59–43.74) | 6.30 (2.11–18.78) |
Adjusted for age, expected insurance payer, national quartile of median household income for residence ZIP code, rural designation of residence, concurrent diagnosis of depression or anxiety, any concurrent mental health diagnosis, ED facility region, ED facility trauma center level, ED facility urban-rural designation, and ED facility teaching status.
None of the pregnant women who received naloxone in the ED were subsequently admitted compared with 40.6% of those who did not receive naloxone. Pregnant women who received naloxone had higher odds of mortality (14% vs 0.39%; aOR: 6.30 (2.11–18.78)) compared with those who did not receive naloxone (Table 4).
Discussion:
Sex and pregnancy status were associated with disparities in naloxone administration in the ED, subsequent admission, and mortality. Compared with men, pregnant and non-pregnant women were less likely to receive naloxone and more likely to be admitted to the ED facility; but had lower mortality with opioid-overdose related ED visits. Pregnant women had strikingly lower odds of receiving naloxone and higher odds of admission compared to non-pregnant reproductive-aged women.
We further identified specific patient characteristics and demographic information contributing to disparities in naloxone use during pregnancy. Pregnant women with Medicaid insurance, in the lowest quartile of median household income for residence ZIP code, and with any concurrent mental health diagnosis were less likely to receive naloxone compared to other pregnant women after adjusting for all other available patient and ED facility characteristics.
Research addressing sex-based disparities in naloxone administration is sparse and reports mixed results.16–17 Faul et al. found that odds of pre-hospital naloxone administration by emergency medical services (EMS) personnel for males were less than females.16 In contrast, another study reported male sex and comorbid disease as predictors for naloxone administration in inpatient and postoperative settings.17 However, sex was significant when adjusting only for patient and hospital characteristics—similar to the methodology of this study. Differences in setting (ED versus pre-hospital versus inpatient and postoperative) likely contribute to differences in detected associations as each setting is comprised of unique health care professionals with varying levels of confidence administering naloxone. Further studies stratifying data based on setting could identify priority areas for education and intervention.
Our data also showed that 81% of pregnant women with opioid overdose-related ED visits had a concurrent mental health diagnosis. Bagley et al. found that 86% of pregnant women in the third trimester with opioid use disorders retrospectively self-reported a mental health diagnosis. However, this cohort was taken from an urban, academic outpatient setting in Massachusetts specializing in caring for pregnant women with substance use disorder.28 These data are supported by Weiss’ report of HCUP data demonstrating that the percent of inpatient stays with a concurrent mental health disorder was twice as high for opioid-related stays than non-opioid-related stays.22 Bagley’s findings—while limited—in combination with our nationally representative data provide further evidence for a high prevalence of mental health disorders in pregnant women who use opioids and a high burden of morbidity for people with mental health disorders.29–30
We also found that pregnant women who received naloxone were more likely to experience mortality in the ED or after admission to the ED facility. We propose explanations for this finding based on clinical experience and previous research. First, pregnant women who need naloxone may be less likely to receive it in the hospital setting. This could result from physician-based differences in assessing the risk-to-benefit ratio of administering naloxone or predilection for including pregnancy-related etiologies in their differential diagnoses. Second, women with fatal opioid overdoses may have had a delay in receiving naloxone until cardiac or respiratory arrest. As such, the decision point to administer naloxone in pregnancy may favor the severe spectrum of disease in which mortality is a more likely sequela. Lastly, previous research found women were less likely to receive life-saving interventions such as cardiopulmonary resuscitation during cardiac arrest when compared to men.31–32
This study has many strengths. The primary and secondary outcomes of reproductive-aged individuals with opioid overdose-related ED visits were stratified by sex and pregnancy status and confounding factors such as patient and ED facility characteristics were included in the analysis to isolate the effects of the defined exposures. NEDS allowed for mortality to be assessed in the ED and during subsequent admission to the facility to reduce information bias due to misclassification. As the use of a CPT code to evaluate naloxone administration is not validated, we confirmed the ICD-10 inclusion criteria for opioid overdose-related ED visits captured the majority of records with a CPT code for naloxone administration. Furthermore, this analysis specifically focused on a time period with current ICD-10 coding practices to reduce any misclassification of cases during the ICD-9 to ICD-10 transition. Overall, the use of the largest all-payer ED database in the US had distinct advantages. It allowed for identification of risk factors for not receiving naloxone in the ED, and evaluation of the health care system’s adherence to clinical guidelines that support the administration of naloxone to pregnant women in the setting of suspected opioid overdose.
Despite the strengths of this study, there are unknowns within the cohort. These findings should be interpreted as hypothesis-generating and in the context of the potential limitations, which may vary by sex or pregnancy status. First, NEDS relies on ED health care professional documentation and likely represents an underestimate of opioid overdose-related ED visits and, particularly, naloxone administration. In tandem, these estimates of ED-based naloxone administration underestimate the health system’s effectiveness as they do not capture pre-hospital community- or EMS-administered naloxone. Second, NEDS only captures ED visits and is not specific to a particular patient. Thus, it is possible that one patient could have had multiple opioid overdose-related ED visits. Third, limited clinical data are available in NEDS, precluding the ability to assess for severity in presentation which contributes to the clinical decision to administer naloxone or not. We were also unable to identify or control for the type of opioid associated with the ED visit. We cannot rule out the effect of Simpson’s paradox if clinical presentation severity or opioid type is unequally distributed among groups and contributes to differing rates of naloxone administration. Severity in presentation also contributes to the clinical decision on hospital admission. As such, performance bias, or the systematic difference in care provided among study groups, may differentially affect the hospital admission rate for pregnant women. Additionally, this study was performed using data that were not created or collected to answer the specific research question.
Lastly, a clear limitation of this study was the inability to assess for disparities based on race or ethnicity. NEDS does not disaggregate data to allow for this analysis. This perpetuates health inequities with the lack of research, representation, and targeted public and clinical health interventions for racial and ethnic minorities. Self-reported race and ethnicity are essential for studying perinatal outcomes as severe maternal morbidity, pregnancy-associated mortality, and pregnancy-related mortality disproportionally affect African American, Hispanic, and American Indian/Alaska Native women.3,8–13
This study found that reproductive-aged non-pregnant and pregnant women were less likely to receive naloxone during opioid overdose-related ED visits compared to reproductive-aged men. The findings contribute new evidence to a robust body of literature demonstrating disparities in clinical and perinatal outcomes for vulnerable populations, including pregnant women who use opioids. Administration of naloxone for suspected opioid overdose among reproductive-aged women should be prioritized in the efforts to reduce opioid- and pregnancy-related morbidity and mortality in the United States.
Supplementary Material
Précis:
Reproductive-aged non-pregnant and pregnant women were less likely to receive naloxone during opioid overdose-related emergency department visits compared with reproductive-aged men.
Acknowledgements:
The authors thank the Johns Hopkins Surgery Center for Outcomes Research for facilitating and supporting the collaborative relationship between the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics. Additionally, the authors thank all the HCUP Data Partners (found at www.hcup-us.ahrq.gov/hcupdatapartners.jsp) who contribute to HCUP.
Funding:
Dr. Vaught’s time is funded by the K12 NIH BIRCWH Award.
Footnotes
Financial Disclosure
The authors did not report any potential conflicts of interest.
Each author has confirmed compliance with the journal’s requirements for authorship.
References
- 1.Mack KA, Jones CM, Paulozzi LJ. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women — United States, 1999–2010. MMWR. 2013;62(26):537–542. [PMC free article] [PubMed] [Google Scholar]
- 2.Paulozzi LJ. Drug-induced deaths--united states 2003–2007. MMWR Morb Mortal Wkly Rep. 2011;60(supp):60–61. [PubMed] [Google Scholar]
- 3.Petersen EE, Davis NL, Goodman D, et al. Vital signs: pregnancy-related deaths, united states, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423–429. 10.15585/mmwr.mm6818e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths--united states, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;ePub. 10.15585/mmwr.mm6550e1 [DOI] [PubMed]
- 5.Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths--united states, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;ePub. https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w [DOI] [PMC free article] [PubMed]
- 6.Wilson N, Kariisa M, Seth P, Smith IH, David NL. Drug and opioid-involved overdose deaths--united states, 2017–2018. MMWR. 2020;69(11):290–297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.World Health Organization. Reproductive health indicators: guidelines for their generation, interpretation and analysis for global monitoring. World Health Organization. 2016:1–63. [Google Scholar]
- 8.Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the united states, 1987–1990. Obstet Gynecol. 1996;88:161–167. [DOI] [PubMed] [Google Scholar]
- 9.Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the united states, 1991–1997. Obstet Gynecol. 2003;101:289–296. [DOI] [PubMed] [Google Scholar]
- 10.Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the united states, 1998–2005. 2010;116:1302–1309. [DOI] [PubMed] [Google Scholar]
- 11.Creanga AA, Berg CJ, Syverson C, Seed K, Bruce C, Callaghan WM. Pregnancy-related mortality in the united states, 2006–2010. Obstet Gynecol. 2015;125:5–12. [DOI] [PubMed] [Google Scholar]
- 12.Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the united states, 2011–2013. Obstet Gynecol. 2017;130:366–373. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees. 2018.
- 14.American College of Obstetricians and Gynecologists. Opioid use and opioid use disorder in pregnancy. committee opinion no. 711. Obstet Gynecol. 2017;130:81. [DOI] [PubMed] [Google Scholar]
- 15.Substance Abuse and Mental Health Services Administration. SAMHSA opioid overdose prevention toolkit. HHS publication no. (SMA) 18–4742PT2. Substance Abuse and Mental Health Services Administration. 2018. [Google Scholar]
- 16.Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple naloxone administrations among emergency medical service providers is increasing. Prehospital Emergency Care. 2017;21(4):411–419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Frank JW, Levy C, Calcaterra SL, Hoppe JA, Binswanger IA. Naloxone administration in US emergency departments, 2000–2011. J Med Toxicol. 2016;12:148–156. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Vivolo-Kantor AM, Seth P, Gladden M, et al. Vital signs: Trends in emergency department visits for suspected opioid overdoses--united states, july 2016-september 2017. MMWR Morb Mort Wkly Rep. 2018;67(9):279–285. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Cash RE, Kinsman J, Crowe RP, Rivard MK, Faul M, Panchal AR. Naloxone administration frequency during emergency medical service events--united states, 2012–2016. MMWR Morb Mort Wkly Rep. 2018;67(31):850–853. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Healthcare Cost and Utilization Project, (HCUP). NEDS overview. https://www.hcup-us.ahrq.gov/nedsoverview.jsp#about. Updated 2020. Accessed March 28, 2020.
- 21.Healthcare Cost and Utilization Project. HCUP nationwide emergency department sample (NEDS). 2017.
- 22.Weiss AJ, McDermott KW, Heslin KC. Opioid-related hospital stays among women, 2016. HCUP statistical brief #247. January 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb247-Opioid-Hospital-Stays-Women.pdf [PubMed] [Google Scholar]
- 23.Weiss AJ, Heslin KC, Barrett ML, Izar R, Bierman AS. Opioid-related inpatient stays and emergency department visits among patients aged 65 years and older, 2010 and 2015. HCUP statistical brief #244. September 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb244-Opioid-Inpatient-Stays-ED-Visits-Older-Adults.pdf [PubMed] [Google Scholar]
- 24.Moore BJ, Barrett ML. Case study: Exploring how opioid-related diagnosis codes translated from ICD-9-CM to ICD-10-CM. U.S. Agency for Healthcare Research and Quality. 2017.
- 25.World Health Organization. Guidelines for the identifications and management of substance use and substance use disorders in pregnancy. World Health Organization. 2014. [PubMed] [Google Scholar]
- 26.Di Rico R, Nambiar D, Stoove M, Dietze P. Drug overdose in the ED: A record linkage study examining emergency department ICD-10 coding practices in a cohort of people who inject drugs. 2018;18:945. 10.1186/s12913-018-3756-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Office of Management and Budget. 2010 standards for delineating metropolitian and micropolitian statistical areas. Federal Register. 2010:Vol. 75, No. 123. [Google Scholar]
- 28.Bagley SM, Cabral H, Saia K, et al. Frequency and associated risk factors of non-fatal overdose reported by pregnant women with opioid use disorder. Addict Sci Clin Pract. 2018;13:26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.McGinty EE, Baller J, Axrin ST, Juliano-Bult D, Daumit GL. Quality of medical care for persons with serious mental illness: A comprehensive review. Schizophr Res. 2015;165(0):227–235 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Thornton D, Guendelman S, Hosang N. Obstetric complications in women with diagnosed mental illness: The relative success of California’s county mental health system. Health Serv Res. 2010;45(1):246–264. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Blewer AL, McGovern SK, Schmicker RH, et al. Gender disparities among adult recipients of bystander cardiopulmonary resuscitation in the public. Circ Cardiovasc Qual Outcomes. 2018;11:e004710. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Safdar B, Stolz U, Stiell IG, et al. Differential survival for men and women from out-of-hospital cardiac arrest varies by age: Results from the OPALS study. Acad Emerg Med. 2014;21:1503–1511 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.